For Physicians: Guidelines and Recommendations

Hysterectomies can be performed via open incision, laparoscopically, and vaginally, with various combinations of the techniques also available.  All of the procedures are effective for performing a hysterectomy; research studies cited here have compared the risks and costs of various procedures.  Physician professional societies have reviewed the evidence and concluded that vaginal hysterectomy is the route of choice for most patients, with laparoscopic or lap-assisted surgery as an acceptable alternative. 

For benign conditions, open abdominal hysterectomy is the least preferred route. Physicians may choose it because it is faster, because they can carry out a higher volume of open procedures or because the physician is not trained in other techniques – but these are not clinically valid reasons. For some invasive procedures there may be clinical indications for an open abdominal hysterectomy.  Patients should be evaluated by surgeons who have capability to perform less invasive techniques, and should only have an open procedure when clinically necessary. 

Clinical Recommendations (evidence, guidelines, specialty societies)

The American Congress of Obstetricians and Gynecologists issued a Committee Opinion in 2009 that examined evidence on the route of hysterectomy for benign (noncancerous) disease.  The Committee recommended that vaginal hysterectomy surgery be considered the route of choice, with laparoscopic hysterectomy also considered a viable alternative to abdominal surgery. The Committee Opinion lists the strengths and weaknesses of each approach and cites evidence.

A Cochrane review (an independent examination of research on a specified subject) compared vaginal, laparoscopic and abdominal hysterectomies.  Based on available research that group concluded that the minimally invasive vaginal approach is preferred, and that laparoscopic surgery is also preferred over abdominal surgery.

AAGL: The AAGL vision is to serve women by advancing the safest and most efficacious diagnostic and therapeutic techniques that provide less invasive treatments for gynecologic conditions through integration of clinical practice, research, innovation, and dialogue. AAGL’s patient care statements provide a rationale for minimally invasive surgery and the organization can help to identify practitioners.

Society of Pelvic and Reconstructive Surgeons: This physician specialty society developed a document, Key Clinical Decision: Determining the Route and Method of Hysterectomy to provide information that physicians can use when choosing between abdominal and vaginal hysterectomy with or without laparoscopic assistance.